Patient Medical Homes (PMH) and Primary Care Networks (PCN)

The GPSC is working toward creating an integrated system of care that enables access to quality primary health care that effectively meets the needs of patients and populations in BC.

Why doctors should get involved

GPs have told us that they need help with:

  • Dealing with the administrative burden.
  • Caring for complex patients.
  • Maximizing a team.

Value proposition
We are freeing you up to do the work you love to do, and
for what brought you into the medical profession in the first place.

This work closely links family doctors to networks of care, including team-based support and specialty services at the practice level and in the community. With this clearer path to care, doctors can get better support to meet the growing needs and complexities of their patients. Patients can more easily move between their doctor’s offices and other health care providers to get quality care.

The health system is under strain on a number of fronts:

  • GPs are under stress and the threat of burnout is real.
  • Many patients can’t find a family doctor.
  • The system is difficult to navigate for patients and doctors.

Given the strains, change is inevitable. The GPSC is ensuring that family physicians remain central decision makers throughout the process and that divisions of family practice play a key role in the evolution of primary care in their communities.

Patient medical homes, primary care networks, and their connection

Patient medical homes (PMH)

The patient medical home is a family practice supported to operate at its full potential. The core of the model is longitudinal care, with the family practice at the centre of primary care. The PMH contains key attributes of what an ideal practice can deliver and how it can best be supported, including through team-based care. The PMH model is being implemented and tested around the world, which has given us the chance to learn from what other people have done. The 12 attributes of a patient medical home in BC are based on College of Family Physicians of Canada’s framework and pillars. The GPSC has adapted the PMH model to recognize the strong networking and partnership work that has already been done through the divisions of family practice, Health Authorities and community partners, as well as the collaborative framework of GPSC that is unique to BC.

Primary care networks (PCN)

As the PMH represents the work within the family practice, the PCN is the system change. Through PCNs, teams of allied health professionals and other health care providers work with physicians, so that everyone can work to their strengths, everyone can support and rely on each other, and patients get the best care. Providing eight core attributes, a PCN is a network of PMHs in a defined geography linked with primary care services that are delivered by a health authority and other organizations and services within that community.

Connecting PMH AND PCN

The patient medical home – the physicians’ practice operating at an ideal level – is at the core of the primary care network. Collectively, PCNs will enable PMHs to expand services for their own practice population, and participate in collaboratively providing access and services to patients in the community not currently attached to a family practice or PMH. 

Proven model of care

There’s strong evidence that a system based on robust primary care is better for the patients, better for the physicians and other providers, and saves the system money.

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Ties to existing work

The groundwork has already been laid by doctors, divisions of family practice, and partners – as they have explored new and better ways to work together and create more unity between providers and the efforts of health authorities to streamline services. Now, with patient medical homes and primary care networks as central to an integrated system, there is an opportunity to bring it all together.

Work underway

The first phase of implementing primary care networks is to increase the number of British Columbians who have access to quality primary care and are attached to a primary care provider.

Across the province, CSCs are starting to plan how to establish and support – through team-based care– formal linkages between doctors and primary and specialized health authority services. Communities will be provided funding for change management in order to develop their service plans to implement primary care networks. CSCs are encouraged to indicate their level of readiness and interest to the GPSC as soon as they are ready. The PCN expression of interest process is ongoing over the next 12 to 18 months. Doctors are encouraged to contact their local division to participate in community planning.

For details about the implementation of the integrated system of primary and community care (in the CSC guidance document), click here.